The patient was a 54-year-old male with recurrent severe coronary artery disease. The following is a partial timeline:
- October 2018: cardiac cath with placement of drug-eluting stent to the left circumflex; did well afterwards
- January 2020: complained of chest tightness & dyspnea while exercising; stress test positive for ischemia
- January 17, 2020: cardiac cath with drug-eluting stent to proximal and mid-LAD; continued complaining of intermittent chest tightness during exercise afterwards
- February 9, 2020: increased Imdur dosing to BID - patient reported improved chest pain. Also taking Brilinta.
- February 18, 2020: admitted with unstable angina diagnosis for possible CABG. Cardiothoracic surgeon thought films suspicious for coronary spasm. Dx CAD w/ stable angina (apparently dx was changed).
- February 19, 2020: cardiac cath done, showed catheter-induced spasm of the right coronary artery; left main 70% obstructed by a discrete lesion. Patent stents in LAD and circumflex.
- February 20, 2020: patient discharged home, to restart home meds including Imdur, statin, aspirin, Brilinta, prn nitroglycerin; plan for CABG in 8-12 weeks.
- March 19, 2020: last dose of Brilinta
- March 20, 2020: readmitted for heparin infusion for planned CABG on March 23.
- March 21, 2020: around 7 am, patient complained of chest pain and was given nitroglycerin; shortly after, had PEA arrest. CPR done for 75 minutes, tPA given and patient taken to cath lab. Left main 90% obstructed and proximal LAD 70% obstructed. PCI done, Impella inserted.
The patient deteriorated and died later that day; autopsy attributed the death to severe trivessel coronary artery disease, found critical stenosis in the left main, LAD, and circumflex with intact, patent stents in each.
We are mainly wondering whether a CABG should have been done in February as originally planned. I realize I may not have included all the facts an expert might consider important, so please let me know if there is information missing that could be determinative.
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Do you believe there might have been medical error?
I think the real question should be whether a 70% left main stenosis was missed on January 17, 2020 when the LAD stent was a laced. I find it quite curious that a cardiac catheterization February 19, 2020 demonstrated 70% left main stenosis, but there was apparently no mention of this when cardiac catheterization was done on month earlier. It will require more detail to determine if there was any breech of the standard of care.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above. Unable to determine without more detail.
What makes you a good expert for this case?
Experienced in both CT Surgery and medical legal review.
How often do you encounter cases similar to this one in your practice?
Patients dying before surgery? Rarely.
Do you believe there might have been medical error?
It is unclear whether the surgery should have been performed in February as originally planned. Importantly, the following question would need to be resolved: What was the planned procedure (i.e., what vessels were going to be bypassed)? Ordinarily, if a patient has patent stents to the LAD and the circumflex, there would be no indication for revascularization of those vessels. Thus, it is not clear why the patient was going to undergo CABG in the first place. If the stents were patent but there was narrowing—either within the stent, beyond the stent, or in another branch—then that might explain the indication for CABG. If, however, we are limited to the facts as presented, I don't even see why a CABG was planned in the first place. The foregoing determination would require a review of both the cath report as well as the cath imaging. In addition, one would need to know the rationale for performing the CABG. If there were an adequate rationale for performing a CABG, one would then need to know the rationale for the delay. Did it have to do with a desire not to perform the surgery so soon after a stent? Sometimes there is a compelling reason for delay.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If indeed there were adequate grounds for proceeding with CABG and if there were inadequate grounds for delay—assumptions for now—causation would very likely have been met. If the patient underwent CABG prior to the episode on March 21, he would more likely than not have survived. CABG in general is associated with a <2% mortality risk, absent other facts that would substantially raise the risk. There do not appear to be any such facts in the fact pattern.
What makes you a good expert for this case?
I am a cardiac surgeon with over 20 years of experience and have performed over a thousand CABGs. I have practiced in both academic and private institutions.
How often do you encounter cases similar to this one in your practice?
Making a decision to delay revascularization in a patient with known coronary artery disease is a fairly common scenario that I encounter at least monthly.
Do you believe there might have been medical error?
young man with recurrent chest pain, unstable angina and multivessel disease. it was appropriate to stent the first coronary (circumflex) the first time, but if there is recurrent ischemia associated with LAD disease, there is indication for CABG. Also, when there is involvement of the left main in a young guy with signs of ischemia, CABG is warranted during that admission.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Not revascularizing surgically the patient to me was a big mistake. The coronary disease progresses and most likely the patient had in-stent thrombosis of the DES previously placed.
What makes you a good expert for this case?
I'm a cardiac surgeon and perform CABGs on a daily basis. I follow my patients before and after the procedure as well.
How often do you encounter cases similar to this one in your practice?
This is a common problem (recurrence of ischemia and progression of coronary disease associated with failure of percutaneous strategies). When a patient comes back with involvement of the left main, especially if young, I always recommend a CABG
Do you believe there might have been medical error?
There are 2 points in the timeline that are of question: 1. January of 2020 - when proximal LAD was noted to be diseased did patient see a surgeon? This is a young patient and proximal LAD disease would best be addressed surgically in non emergent situation. 2. February of 2020 - Indeed the question is why the surgery is deferred 8-12 weeks. At my institution Cardiologists expect that we operate on a patient diagnosed to have left main disease within 7 days (unless patient does not want obviously).
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again, was there heart team (surgery) consultation when proximal LAD disease was discovered? Did patient turn down surgery that was offered at that time? After discovery of left main disease why was there such a long delay (8-12 weeks) before surgery was planned?
What makes you a good expert for this case?
I am a cardiac surgeon and do mostly coronary bypass operations.
How often do you encounter cases similar to this one in your practice?
Left main cases come about every few weeks.
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